MRSA Colonization Clinical Trial
Official title:
A Novel Approach to MRSA Screening of Colonized Patients and Impact on Hospital Resource Allocation and Patient Care
Methicillin-resistant Staphylococcus aureus (MRSA) is endemic in hospital settings. Colonization with MRSA puts patients at increased risk for invasive infections, and MRSA infections have been associated with high costs and adverse clinic outcomes. Patients can clear MRSA spontaneously. Improved approaches for identifying patients who are no longer colonized are needed; we hypothesize that more sensitive nucleic acid amplification can be used to improve identification of patients who are no longer colonized.
Compared with patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia,
patients with MRSA bacteremia remained in the hospital for two more days on average and had a
median attributable increment in hospital charges of approximately $7000.
MRSA status is a determinant of bed allocation, especially in shared-room settings, which
represent the most common organization in the US and globally. Based on guidelines from the
Centers for Disease Control and Prevention, once patients are designated as having had a
positive MRSA culture (either colonized or from a clinical isolate), they require Contact
Precautions. This requirement translates into either cohorting with other patients with
similar precautions status (i.e., two patients with MRSA share a room) or placement in a
private room in the hospital. Cohorting is not the preferred infection control method, but in
shared-room settings, it is the most common scenario, particularly in hospitals with high
occupancy.
Individuals can clear MRSA colonization spontaneously. In fact, up to 38% of patients with
MRSA-positive cultures taken greater than 3 months prior were found to be MRSA-negative
during a re-screening program conducted by the Massachusetts General Hospital Infection
Control Unit from 2004-2006. Other studies have demonstrated that a majority of patients are
likely to clear colonization at various time points from original documentation of MRSA
infection or colonization. There is currently no standardized approach or accepted guidelines
for addressing screening for clearance of colonization in the growing pool of patients who
have previous MRSA colonization/infection. Many organizations do provide guidelines for
screening, but these guidelines are not based on rigorous study, have a variety of
permutations, and have neither consensus acceptance nor adequate implementation among the
medical community.
The status quo limits bed availability and delays patient discharge to rehabilitation
facilities, adversely affecting quality and efficiency, and resulting in use of additional
hospital resources. In addition to problems associated with patient flow for admissions and
discharges, precaution status results in additional disruptions of patient care through "bed
moves" to accommodate the use of shared rooms by like patients needing Contact Precautions.
A patient's precaution status affects his/her care from admission through discharge. During
pre-admission, patients identified as previously having MRSA are affected by bed shortages
and delays to admission while in emergency departments. While admitted, under current
practices, patients who have in fact cleared MRSA may be cohorted with those who have active
infection or persistent colonization, putting them at risk of recolonization and hospital
acquired infection (HAI). Finally, patients who are on precautions for MRSA often have
delayed discharge to rehabilitation or nursing facilities because of bed constraints similar
to those experienced by acute care facilities.
We hypothesize that the use of more sensitive Polymerase Chain Reaction (PCR) methods
detecting MRSA in nasal swabs can facilitate identification of true negative patients and can
reliably do so with a single negative test in a shorter period of time, thereby greatly
facilitating the ability to complete testing on a larger proportion of patients.
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